Pathways to reproductive autonomy: Using path analysis to predict family planning outcomes in the United States

Abstract In the United States, about half of pregnancies are unintended, and most women of reproductive age are at risk of unintended pregnancy. Research has explored predictors of contraceptive use and unintended pregnancy, but there is a lack of research regarding access to preferred contraceptive method(s) and the complex pathways from sociodemographic factors to these family planning outcomes. This study applied Levesque et al.'s (2013) healthcare access framework to investigate pathways from sociodemographic factors and indicators of access to family planning outcomes using secondary data. Data were collected at four time points via an online survey between November 2012 and June 2014. Participants were US women of reproductive age who were seeking to avoid pregnancy (N = 1036; Mage = 27.91, SD = 5.39; 6.9% Black, 13.6% Hispanic, 70.2% white, 9.4% other race/ethnicity). We conducted mediational path analysis, and results indicated that contraceptive knowledge (β = 0.116, p = 0.004), insurance coverage (β = 0.423, p < 0.001), and relational provider engagement (β = 0.265, p = 0.011) were significant predictors of access to preferred contraceptive method. Access to preferred contraceptive method directly predicted use of more effective contraception (β = 0.260, p < 0.001) and indirectly predicted decreased likelihood of experiencing unintended pregnancy via contraceptive method(s) effectiveness (β = −0.014, 95% confidence interval: −0.041, −0.005). This study identifies pathways to and through access to preferred contraceptive methods that may be important in determining family planning outcomes such as contraceptive use and unintended pregnancy. This information can be used to improve access to contraception, ultimately increasing reproductive autonomy by helping family planning outcomes align with patients' needs and priorities.


| INTRODUC TI ON
Unintended pregnancy is associated with lower quality of life and with increased distress, depression and anxiety for the pregnant person during and after pregnancy and is also linked to poor maternal and child health outcomes (Gipson et al., 2008;Leathers & Kelley, 2000;Schwarz et al., 2008). In the United States, 40%-45% of pregnancies are unintended Finer & Zolna, 2016), and a majority of women of reproductive age are at risk of unintended pregnancy (i.e. having sex with a man and desiring to avoid pregnancy; Jones et al., 2015).
Nationally representative data suggest that, over the course of a year, about 85% of heterosexual couples not using contraception will become pregnant (Trussell, 2011). When used consistently and correctly, user-dependent hormonal contraceptive methods (i.e. vaginal ring or contraceptive pill, patch or injection) can be highly effective, preventing over 99% of pregnancies (Guttmacher Institute, 2015;National Health Service, 2020). However, when these methods are used incorrectly or inconsistently, their effectiveness declines (Guttmacher Institute, 2015;NHS, 2020). US women who use contraception consistently and correctly account for only 5% of unintended pregnancies, whereas inconsistent contraceptive use accounts for 41% of unintended pregnancies (Guttmacher Institute, 2015). Some contraceptive methods, such as natural family planning methods (e.g. monitoring monthly fertility patterns and timing sexual encounters to avoid pregnancy) and withdrawal, are highly susceptible to user error, resulting in variable effectiveness (NHS, 2020;Urrutia et al., 2018). In contrast, sterilisation and longacting reversible contraception (LARC), including the contraceptive implant and intrauterine devices (IUDs) are highly effective methods (greater than 99% effective) with greatly reduced opportunities for user failure (Guttmacher Institute, 2015; NHS, 2020).

| Guiding framework
Contraceptive access promotes reproductive autonomy and reduces the risk of unintended pregnancy. Levesque et al.'s (2013) healthcare access framework is useful in understanding the many factors influencing contraceptive access. This framework conceptualises access to healthcare as determined by five dimensions that interact to generate healthcare access: (1) approachability, (2) acceptability, (3) availability and accommodation, (4) affordability and (5) appropriateness. Applying this framework to contraceptive access provides a holistic approach to examining the many barriers to and facilitators of access to contraception.
According to Levesque et al.'s (2013) framework, the first dimension of healthcare access is approachability, which requires community members to perceive the need for care. In particular, the availability of contraceptive information and the transparency of contraceptive services impact the approachability of contraceptive care (Bessett et al., 2015). Lack of contraceptive knowledge is a common barrier to contraceptive access, as many US women lack information about birth control and misestimate its effectiveness (Cabral et al., 2018;Frost et al., 2012). Women with more contraceptive knowledge are more likely to use contraception and to use more effective methods than women with less contraceptive knowledge (Frost et al., 2012;Guttmacher Institute, 2015;Guzzo & Hayford, 2018).
The second dimension of healthcare access, acceptability, refers to the ability to seek care, with health beliefs and social norms either promoting contraceptive access or creating stigma, shame and lack of trust in healthcare systems (Holt et al., 2020;Levesque et al., 2013). Over half of US women of reproductive age consider pregnancy avoidance very important, and almost a quarter would be very unhappy to become pregnant (Jones, 2017). However, 36% of US women of reproductive age report some degree of pregnancy fatalism, indicating that many women believe that the occurrence or timing of pregnancy is outside of their control (Jones, 2018).
Research suggests that contraceptive use is predicted by pregnancy fatalism and by the importance of pregnancy avoidance to the contraceptive user, with women who desire to and believe they can prevent pregnancy being more likely to use contraception (Frost et al., 2012;Hamidi et al., 2018;Jones, 2017).
The third dimension of Levesque et al.'s (2013) framework, availability and accommodation, refers to the ability to physically reach care in a timely manner. This dimension of contraceptive access is influenced by the availability of over-the-counter contraception options, the distance patients must travel for services, clinic hours of operation and the availability of transportation needed to reach care (Holt et al., 2020;Kennedy et al., 2019; What is known about this topic • Unintended pregnancy is common and is associated with negative health and mental health outcomes.
• Preventing unintended pregnancies and promoting reproductive autonomy requires access to contraception.
• Healthcare access is multidimensional and requires approachable, acceptable, available, affordable and appropriate care.

What this paper adds
• Contraceptive knowledge, insurance coverage and provider engagement predicted access to the preferred contraceptive method, which emphasises the approachability, affordability and appropriateness dimensions of healthcare access.
• Access to the preferred contraceptive method directly predicted use of more effective contraception; it also mediated the relationships between predictors (contraceptive knowledge, insurance coverage and provider engagement) and family planning outcomes (contraceptive method(s) effectiveness and unintended pregnancy). Levesque et al., 2013). These issues can produce barriers to contraceptive care (Pratt et al., 2014), especially for low-income people and those living in rural areas (Beeson et al., 2014;Sundstrom et al., 2019).
The fourth dimension of healthcare access, affordability, refers to patients' ability to pay for care, which depends on patient income, access to health insurance and the cost of services (Levesque et al., 2013). The cost of family planning services and lack of health insurance are some of the most common barriers to contraceptive care (Pratt et al., 2014;Zimmerman, 2017). Health insurance is a key aspect of contraceptive affordability (Levesque et al., 2013;Swan et al., 2020) with studies showing that women with insurance are more likely to use contraception and to use more effective contraception than uninsured women Nearns, 2009). A dramatic change to contraceptive affordability has occurred over the past decade, related to the Affordable Care Act (ACA). The ACA expanded health insurance coverage and Medicaid eligibility and mandated contraceptive coverage as a preventive service (Redhead & Kinzer, 2015;Sonfield, 2011). The ACA has led to increased contraceptive affordability by decreasing out-of-pocket contraceptive costs (e.g. Finer et al., 2014;Sonfield et al., 2015) and uninsurance rates (e.g. Decker et al., 2018;Johnston & McMorrow, 2020). Furthermore, states that took advantage of optional Medicaid expansion under the ACA have seen increased public insurance coverage (e.g. Boudreaux et al., 2019;Gibbs et al., 2020), decreased uninsurance (e.g. Boudreaux et al., 2019;Hale et al., 2018), and decreased cost as a barrier to care (Johnston et al., 2018).
Finally, appropriateness refers to patients' ability to engage in their contraceptive care (Levesque et al., 2013). In order for patients to engage with providers for appropriate contraceptive care, providers must be adequately trained and prepared to provide unbiased care that matches their patients' needs and priorities (Casey & Gomez-Lobo, 2013;Gomez et al., 2014;Holt et al., 2020;Swan et al., 2020). Scholars and public health advocates have recommended that healthcare providers assess patients' reproductive life plans and tailor contraceptive decision-making support based on patients' needs and priorities (Casey & Gomez-Lobo, 2013;Dehlendorf et al., 2014;Holt et al., 2017). Research shows that when patients experience this sort of provider engagement during contraceptive counselling, they are more likely to initiate or continue contraceptive use and maintain the use of a highly effective method (Dehlendorf et al., 2016;Lee et al., 2015).

| Study purpose
Most family planning research has traditionally focused on contraceptive uptake, adherence, and/or effectiveness. While these are important family planning outcomes, they are reflective of broader public health goals rather than indicators of reproductive autonomy. In order to understand the multifaceted barriers to reproductive autonomy as well as their relationships with more traditional family planning outcomes, the current study focused on the ability to access preferred contraceptive methods and the complex pathways from sociodemographic factors and indicators of access to traditional family planning outcomes (i.e. contraceptive effectiveness and unintended pregnancy). This study applied Levesque et al.'s (2013) healthcare access framework to investigate direct and indirect pathways from pregnancy fatalism, insurance status, provider engagement, family planning Medicaid expansion and contraceptive knowledge to family planning outcomes. Broadly, we hypothesised that these predictors would have a direct effect on contraceptive method(s) effectiveness and unintended pregnancy as well as an indirect effect via the ability to access preferred contraception. The conceptual model and hypothesised effects are shown in Figure 1, and the specific hypotheses are listed in Appendix A.

| Data and sample
We used panel data collected by the Guttmacher Institute (n.d.) using address-based sampling. Data were collected at four time points from November 2012 to June 2014. This online survey collected information about contraceptive use, pregnancy motivation and healthcare access. Participants were US women aged 18-39 years who, at baseline, had ever had vaginal sex with a man, were not pregnant, had not had a tubal ligation, and whose main sexual partner had not had a vasectomy. Respondents chose whether to take the survey in English or Spanish and received $10 compensation for each completed wave. We received confirmation from the Virginia Commonwealth University Institutional Review Board (IRB) that this secondary data analysis did not require IRB review due to not qualifying as human subject's research.
There were 6 months between each survey wave, with 4634 women completing wave 1, 3207 women completing wave 2, 2398 women completing wave 3 and 1842 women completing wave 4.
Participants who completed all four waves were more likely than those who dropped out of the study to be older, insured, have access to their preferred contraceptive method, have lower education and pregnancy fatalism, and use more effective contraception.
Participants identifying their race/ethnicity as white or other were more likely to complete all four survey waves whereas those identifying as Black or Hispanic were more likely to drop out before wave four. See Appendix B for more study attrition information.
Women who were actively trying to get pregnant or reported that pregnancy avoidance was not important to them were excluded from the current study. Removal of these cases from the dataset yielded a sample size of 1247. Only cases with complete data for each variable were included in the current analysis (N = 1036). Among those who participated in all four survey waves, there was a low rate of missing data (i.e. 0.2%-1.0%), although 14.7% of participants skipped the item assessing the ability to access preferred contraception. Participants who were older, uninsured, Black, lacking provider engagement, using less effective contraception and having sex less frequently were more likely to be missing data on this variable. See Appendix B for more information about missing data.

| Contraceptive knowledge
Contraceptive knowledge was assessed at wave one by asking how much participants knew about pregnancy prevention methods.
Response options ranged on a 6-point Likert-type scale from "I know nothing" (=0) to "I know everything" (=5). This variable reflects the approachability dimension of healthcare access.

| Pregnancy fatalism
Pregnancy fatalism was measured in wave one by asking how much participants agreed with the statement: "It doesn't matter whether I use birth control, when it is my time to get pregnant, it will happen." Response options ranged from "strongly disagree" (=0) to "strongly agree" (=4). This variable reflects the acceptability dimension of Levesque et al.'s (2013) healthcare access framework.

| Insurance status
Insurance status was assessed in wave one using two items.
Participants were asked about their health insurance coverage, and those reporting insurance coverage were asked if they had coverage throughout the past 6 months. A dichotomous variable was created with participants who had insurance for all of the last 6 months coded as insured (=1) and participants reporting no insurance or gaps in insurance coded as uninsured (=0). This variable reflects the affordability dimension of healthcare access.

| Family planning medicaid expansion
Using the 2011 Title X Family Planning Annual Report (Fowler et al., 2012), a dichotomous variable was created indicating whether, in November/December 2012, participants lived in a state that had expanded family planning Medicaid in the previous year (=1) or lived in a state without expansion (=0). Along with insurance status, this variable reflects the affordability dimension of healthcare access.

| Provider engagement
In wave one of the survey, we measured participants' engagement with healthcare providers with four items, which were split into two composite variables that assessed different aspects of provider F I G U R E 1 Hypothesised path analysis model. Model adjusted for the effects of age, age 2 , race/ethnicity and education. T1 = Time 1; T2 = Time 2; T3 = Time 3; T4 = Time 4  (2) informative provider engagement. Participants who did not report visiting a women's health provider in the past 6 months were coded as not experiencing provider engagement (=0) and those reporting visiting such a provider were asked follow-up questions about provider engagement.

Hypothesized Path Analysis Model Hypothesized Path Analysis Model
Relational provider engagement reflected encounters in which healthcare providers assessed and satisfactorily met patient needs. This variable was assessed by asking how much participants agreed: (1) that the people working at the facility tried to find out their healthcare needs and (2) that they were satisfied with the care they received there. Participants who reported "strongly agree" and/or "somewhat agree" for either or both items were coded as experiencing relational provider engagement (=1), and those reporting "strongly disagree" and/or "somewhat disagree" for both items were coded as not experiencing relational provider engagement (=0).
Informative provider engagement reflected encounters in which healthcare providers shared contraceptive information with pa- Participants with implants, IUDs, tubal ligation or partners with vasectomies were coded as long-acting or permanent contraceptive users (=4). Participants who reported using the pill, patch, ring or contraceptive shot were coded as user-dependent hormonal contraceptive users (=3) as long as they reported missing 0-1 pills or starting the method on time or 1 day late. Participants who reported slightly imperfect use of user-dependent hormonal methods (e.g. 2-4 days of missed pills) but also reported using a rhythm/barrier method during the last 30 days were also classified as consistent user-dependent hormonal contraceptive users (=3). Participants who used the same barrier method every time they had sex or reported using multiple rhythm/barrier methods in a way that suggested at least one method was used every time they had intercourse were categorised as barrier contraceptive users (=2). Participants who reported inconsistent use of one of the above methods were coded as inconsistent contraceptive users (=1). Finally, participants who reported that they did not use any of the above methods or reported only using withdrawal or natural family planning were coded as nonusers of contraception (=0).

| Unintended pregnancy
Unintended pregnancy was assessed using three items at wave four.
The first item asked about participants' experiences with pregnancy since the prior survey wave, with response options: "I had a miscarriage," "I had an abortion," "I had a baby," "I'm currently pregnant," "I might be pregnant," and "none of the above." Participants reporting a pregnancy since the previous wave were then asked, "Right before you became pregnant this time, did you yourself want to have a(nother) baby at any time in the future?" Participants responding "yes" to this item were asked about the timing of their pregnancy.
If they reported no pregnancy or being unsure if they were pregnant, they were coded as not experiencing an unintended pregnancy (=0). Participants reporting a pregnancy and responding "yes" for wanting a baby were coded as no unintended pregnancy (=0) if they answered, "at about the right time" or "later than you wanted" for the timing of the pregnancy and were coded as experiencing an unintended pregnancy (=1) if they answered, "too soon." Participants reporting a pregnancy and reporting "no," "do not know," or "did not care" for wanting a baby were coded as experiencing an unintended pregnancy (=1).

| Demographic variables
Race/ethnicity, education and age were included as control variables due to known disparities in family planning outcomes based on these factors (Finer & Zolna, 2011

| Data analysis
After describing our study sample, we conducted path analysis in Mplus 8.0 using the robust weighted least squares (WLSMV) estimator to assess the direct and indirect pathways from baseline pregnancy fatalism, insurance status, provider engagement, contraceptive knowledge and family planning Medicaid expansion to access to preferred contraception, contraceptive method(s) effectiveness and unintended pregnancy. Frequency of sex was also included as a predictor of contraceptive method(s) effectiveness and unintended pregnancy. Age, age squared, education and race/ethnicity were included as control variables. Grounded in theoretical and conceptual knowledge about these constructs, some direct pathways from the baseline to outcome variables were constrained, 1 as shown in

| Descriptive statistics
As shown in Table 1

| Path analyses
The hypothesised model had good fit for the data (χ 2 = 8.049, Standardised specific indirect effect estimates (see Table 3) in-

| DISCUSS ION
The aim of this study was to investigate direct and indirect pathways from sociodemographic factors and predictors of healthcare access to family planning outcomes. Our results indicate that contraceptive knowledge, insurance coverage and relational provider engagement are significant predictors of the ability to access the preferred contraceptive method and that there is an indirect effect of access to preferred contraception on unintended pregnancy. These findings support theoretical suppositions about factors that are key to contraceptive access and extend previous work showing relationships between individual family planning constructs.
Previous research suggests that health insurance Nearns, 2009), provider engagement (Dehlendorf et al., 2016;Lee et al., 2015), and contraceptive knowledge (Frost et al., 2012;Guzzo & Hayford, 2018) are important predictors of family planning outcomes. This study corroborates these findings and extends previous research by suggesting that these are also important predictors of access to preferred contraception and that access to the preferred contraceptive method may be the mechanism by which these factors impact family planning outcomes. In this sample, which had relatively high levels of self-reported contraceptive knowledge, this knowledge played an important role in determining the ability to access the pre- This study also explored the role of healthcare provider engagement in predicting family planning outcomes. Our findings indicated that provider engagement based in relationship played a more important role in determining these outcomes than that focused on the provision of information. This is an important contribution of this study, as provider engagement is often considered a one-dimensional construct, and many interventions targeting family planning outcomes    (Dunlop et al., 2016;Sonfield & Gold, 2011) and decreases unintended pregnancy (Adams et al., 2015;Sonfield & Gold, 2011

| Strengths and limitations
Several limitations should be considered when interpreting these findings. As with most longitudinal studies, some participants who initially responded to the survey did not participate in all four waves.
In this case, only 40% of the baseline sample was retained through all four waves, and participants who dropped out between waves one and four differed on key variables from those who completed all four waves. As described elsewhere ,  Steinberg et al., 2013). Although the use of ordinal variables can limit analysis options and increase opportunities for measurement error, it also allows for the retention of maximum information in situations where it is impossible to observe or calculate numerical values across an interval or ratio scale; moreover, sufficient analysis methods exist to handle this type of variable (Li, 2014;Nussbeck et al., 2006). Considering the benefits and limitations of using ordinal variables, future research could develop and compare alternative methods for measuring contraceptive use and consolidating this information in ways that capture the maximum amount of information.
Finally, these data were collected from 2012 to 2014. This produces findings related to contraceptive access at a critical moment in time when the family planning landscape was shifting related to the implementation of the Affordable Care Act. Continued policy changes have occurred since this data collection, and additional research is needed to replicate these analyses in more contemporary samples.
In addition to these limitations, this study has several important strengths. We are among the first to leverage path analysis methodology to study complex multivariate pathways to family planning outcomes. This study also draws important connections between common family planning outcomes (contraceptive effectiveness and unintended pregnancy) and more accurate and contemporary reflections of reproductive autonomy (preferred contraceptive use). There are few national data sources available containing these nuanced measures of reproductive autonomy across multiple survey waves, and as a result, there have been few longitudinal studies examining reproductive autonomy.

| CON CLUS ION
This study identifies pathways to and through access to preferred contraceptive methods that may be important in determining family planning outcomes such as contraceptive use and unintended pregnancy. In particular, contraceptive knowledge, insurance coverage and relational provider engagement were important predictors of the ability to access the preferred contraceptive method. This information can be used to improve access to contraception, ultimately increasing reproductive autonomy by helping family planning outcomes align with patients' needs and priorities.

AUTH O R ' S CO NTR I B UTI O N
The initial idea for this paper came from LS. SM and SP helped finalise the variable conceptualisation and analysis plan. SM provided methodological consultation, and LS ran the analysis. LS drafted the manuscript with guidance and edits from SM and SP. Final edits and subsequent revisions were led by LS with input from all authors.

ACK N OWLED G EM ENTS
The authors thank dissertation committee members Dr Youngmi Kim and Dr Sarah Jane Brubaker for their support and guidance in preparing this project.

CO N FLI C T O F I NTE R E S T
The authors have no conflict of interest to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are from the Guttmacher Institute's Continuity and Change in Contraceptive Use Study. The data can be requested at https://www.guttm acher.